Questões de Saúde Lésbica

Lesbian Health Issues Paper

QAHC Lesbian Health Action Group

Prepared by Kate Allen

10 May 2009

Promoting the health and well-being of lesbian, gay, bisexual and transgender (LGBT) Queenslanders

Contents
Foreword........................................................................................1
Definitions of Sexual Orientation...................................................2
QAHC Lesbian Health Action Group..............................................4
Introduction. ..................................................................................5
.
Accessing Health Care. .................................................................6
.
Cancer Screening & Prevention....................................................7
Stigma and Discrimination..........................................................10
Mental Health..............................................................................14
Alcohol, Tobacco and Other Drug Use.........................................15
Relationships...............................................................................18
Sexual Health...............................................................................20
Pregnancy and Parenting............................................................21
Domestic Violence.......................................................................22
Obesity and Overweight...............................................................23
Health Service Delivery...............................................................24
Conclusion...................................................................................26
Reference List..............................................................................27

Foreword

This paper has been written to inform the work of the QAHC Lesbian Health Action Group
(QLHAG) in developing a Queensland Lesbian Health Strategy. The paper does not seek to be
a comprehensive academic literature review of all issues relating to lesbian health, but rather
seeks to highlight current, urgent and relevant health issues pertinent to Queensland Lesbians.
The paper is designed to be brief and user-friendly so that it is readily utilised in raising
awareness of lesbian health issues. Evidence used in the paper is from an Australian (preferably
Queensland) context and has been selected based on currency, relevance, and on the significance
of the health issues that impact on the lesbian community.

Whilst we have conducted an extensive search of the literature related to lesbian health over
many months, we apologise in advance for any omissions. Our aim has been to present the most
important and relevant evidence at hand. Further, we acknowledge that research on lesbian
health issues is difficult to compare and analyse due to the wide variances in methodological
preparations of study populations (Mravcak, 2006). Some studies use three categories
(homosexual, bisexual or heterosexual) whereas others use large scales of up to seven
categories to classify sexual orientation. This means more or less women may be captured in the
various studies. This methodological phenomenon has been taken into account when reviewing
the evidence presented herein.

Lesbian Health Issues Paper - October 2009 1

Definitions of Sexual Orientation

For the purpose of academic exercise, definitions of women’s sexual orientation are useful.
Though as individuals, the lives of women, the choices they make and the way they choose to
express their love and sexuality are as diverse as their finger prints. Women’s sexual orientation
seems far less able to be categorised by classical stage theories and is far more about individual
factors, especially their emotions and environmental contexts. Women’s sexual orientation and
sexuality has been described as ‘potentially fluid, changeable over time and variable across social
contexts’ and more ‘culturally and contextually malleable’ than men’s (Peplau & Garnets, 2000;
Veniegas & Conley, 2000). Popular opinion suggests women’s sexual orientation fits within a
continuum model. This is in contrast to traditional academics who have used a dichotomy model
to theorise about homosexual men and women (Veniegas & Conley, 2000).

The paradigm shift towards a continuum model in the exploration of sexual orientation is an
exciting development for lesbian and feminist studies. It moves away from the stifling model
of homosexual versus heterosexual, which has been purported by patriarchal theorists. The
continuum theory empowers women against those who aim to engage and categorise non-
conforming individuals, which is an academic approach that only leads to oppression and
stigmatisation of non-heterosexuals in our society. An acceptance of the fluidity of women’s
sexual orientation is particularly useful for young women, and may lead to reducing the stressor
associated with coming out and may assist in the establishment of a woman’s sexual identity.
Often, and most particularly for bisexual or ‘bicurious’ young (or indeed older), women feel
compelled to ‘come out’ as a ‘real lesbian’ and denounce any attraction for males. The continuum
model relaxes the social pressure from lesbians and heterosexuals alike. It allows young women
forming their sexual identity to be free to sample a variety of life experiences without having to
‘commit’ to a life of ‘heterosexualdom’ or ‘lesbianhood’. Discourse about a woman’s perceived
choice over her sexual orientation is important because where an individual perceives choice over
their personal preferences and lifestyle, they experience more empowerment and are less likely
to feel victimised by their circumstance.

The term ‘Queensland lesbians’, for the purpose of this paper and the work of the QLHAG,
refers to all people who identify as lesbian, bisexual and same sex attracted women (SSAW) in
Queensland. This group includes, but is in no way limited to, lesbians, gay women, dykes, women
who have sex with women (WSW), women-partnered women (WPW), queer women, lezzos, SSAW,
lipstick lesbians, sporty dykes, of Sapphic inclination, butch lesbians, bull dykes, stone butches,
femmes, lesbian transwomen, gender queer people, diesel dykes, baby dykes, stealth dykes,
transdykes, bicurious women, non-heterosexual women, fluid, androdykes, bois, bulldaggers,
vagitarians and anyone who is on this side of the fence, on our team or one of us (apologies for
anyone missed, please contact the author for amendments).

2 Lesbian Health Issues Paper - October 2009

Acknowledgements

QLHAG would like to acknowledge the lesbians and SSAW of Queensland as the experts in
their health needs, and seeks only to provide structure, awareness and support to the lesbian
community in their health needs. Further, we thank them for sharing their stories with us so far,
which are weaved into this paper.

QLHAG would like to acknowledge the workers, volunteers and supporters of QAHC, without
whose vision, advocacy and support, would not be in a position to advance lesbian health in
Queensland.

QLHAG would like to acknowledge the ACON (AIDS Council of New South Wales) Lesbian Health
Project, particularly their development of Turning Point: ACON Lesbian Health Strategy 2008-
2011, from which we have drawn much inspiration, guidance and resources.

The author would like to gratefully acknowledge:

• Shane Garvey, QAHC ATODS Project Officer, for the section on Alcohol, Tobacco and
Other Drugs
• Carol Jeffrey, QAHC Board Member, for the section on Obesity and Overweight
• National LGBT Health Alliance, for the section on Health Services Delivery
• The editors and proofreaders, who include:
yy Melinda Zerner;
yy Paul Martin; and
yy Jacinta Walker


QAHC Lesbian Health Action Group
(Adapted from the QLHAG Terms of Reference)

The QLHAG was developed in September 2008 by a group of lesbians who were concerned and
compelled to act on the growing health needs of their community. Most of these women are
associated with the health care sector and volunteer their time to raise awareness of the health
issues mentioned in this paper. The QLHAG is auspiced by QAHC (Queensland Association of
Healthy Communities) which is a lead LGBT health promotion organisation in Queensland.

The goals of the QLHAG are:

1. To improve the health and wellbeing of lesbians and same sex attracted women (SSAW) in
Queensland

2. To build on past and current health initiatives and the existing strengths and resources
of women

3. To develop new and innovative responses in lesbian health using evidence-based practice

(Adapted from Turning Point: ACON Lesbian Health Strategy 2008-2011)

Membership in the Action Group is open to all those who support the goals of the Group and
are willing to work to achieve them. The Action Group is comprised of Core Members who are
responsible for generating outcomes and a wider Network which will serve to inform the work
of the Core. The Core Members will provide regular feedback to the Network Members on the
progress and action of QLHAG. Membership to the Core Group is open and demonstrated by
ongoing participation at Action Group Meetings and in business.


Introduction

Lesbians remain largely unrecognised and inadequately catered for in the wider context
of women’s health. For many reasons, lesbians experience poor outcomes in the areas of:
alcohol and drug use, weight management, sexual health and most significantly, psychosocial
maladaption with potential associated mental health issues. There is no primary reason that
clarifies why lesbians participate in health behaviours, which are deleterious to their health
status. Most likely, the psychosocial stress of living in a heterosexist environment creates a
burden, which manifests as harmful self-soothing behaviours leading lesbians to potentially
poorer health outcomes.

The Key Health Action Areas identified by the QLHAG are outlined below. Whilst most of the
health issues are interdependent of each other, they are examined separately. This is due to the
different stakeholders and service providers responsible for each health issue in our community.

• Accessing Health Care
• Cancer Screening & Prevention
• Stigma and Discrimination
• Mental Health
• Alcohol, Tobacco and other Drug Use
• Relationships
• Sexual Health
• Pregnancy and Parenting
• Domestic Violence
• Obesity and Overweight

Some groups of women within the wider lesbian community are particularly vulnerable to the
impacts of health inequities, including:

• culturally and linguistically diverse women;
• indigenous women;
• older women; and
• women with disabilities.

This paper intentionally addresses health issues, not the effects on specific populations in
the lesbian community. It is acknowledged that all of the abovementioned health issues affect
vulnerable groups in different ways and may require specific and targeted interventions.


Accessing Health Care

Anecdotal evidence collected from outreach work by the QLHAG suggests many Queensland
lesbians experience difficulty in finding a lesbian-friendly General Practitioner (GP). The reasons
for this include general difficulties in finding a skilled GP they can communicate clearly with,
concerns of disclosure of sexual orientation and negative past experiences with GPs when
sexual orientation has been disclosed. Alarmingly, myths about health care needs of lesbians
are prevalent in some lesbian communities. Some women have been told by their GPs they do
not need Pap smears because they have never been sexually active with a man. Lesbian GPs
and the promotion of lesbian-friendly GPs are uncommon in metropolitan Queensland. They are
even scarcer in regional and rural Queensland. Poor access to health care is predictive of poorer
health outcomes for all people, including lesbians (World Health Organisation, 1986).

The likelihood of a woman disclosing her sexual orientation to a treating health care worker
is positively associated with regular health care use. Whether a lesbian discloses her sexual
orientation to a health care worker is dependent on provider-related characteristics such as
perceived gay-positivity, gay-friendly environmental factors, such as rainbow flags and lesbian
images on posters in waiting rooms, and provider inquiry about sexual orientation, rather than
patient factors such as ‘outness’ (Polek & Crowley, 2008; Steele, Tinmouth, & Lu, 2006; Mravcak,
2006; Mulligan & Heath, 2007). Lesbians use a variety of strategies to secure health practitioners
who are accepting of their sexuality. Strategies include, personal recommendations from trusted
sources, ‘interviewing’ of the health care provider before disclosure of sexual orientation and
‘educating’ health care providers who are not experts in lesbian health issues (Mulligan &
Heath, 2007).

Bisexual women and women who identify as ‘mainly heterosexual’ are less likely to disclose their
sexual orientation than lesbian women, and often protect their relationship with their health care
providers through non-disclosure (Polek & Crowley, 2008). The Victorian Private Lives Survey
reports that 65.7% of lesbian and bisexual women were ‘out’ to their GP and 65.9% had had a
‘check up’ in the last year (Pitts, Smith, Mitchell, & Patel, 2006).


Cancer Screening & Prevention

Theoretical risk factors for
developing breast cancer
which are increased in lesbians
include obesity, use of alcohol,
reproductive risk factors such
as nulliparity (never having
given birth to a child), lower
contraceptive use and older age
at first child birth.
(Brandenberg, Matthews, Johnson, & Hughes, 2007; Pitts,
Smith, Mitchell, & Patel, 2006;
Cochrane, et al., 2001).

Breast Cancer Screening
Breast cancer is the second most common cause of cancer-related death in women in Australia
and age is the biggest risk factor in developing the disease (Australian Institute of Health &
Welfare & Department of Health and Ageing, 2008). Over 75 per cent of breast cancers occur
in women 50 years and over and early detection increases a womwan’s chance of survival
(Australian Institute of Health & Welfare & Department of Health and Ageing, 2008). Theoretical
risk factors for developing breast cancer which are increased in lesbians include obesity, use of
alcohol, reproductive risk factors such as nulliparity (never having given birth to a child), lower
contraceptive use and older age at first child birth. (Brandenberg, Matthews, Johnson, & Hughes,
2007; Pitts, Smith, Mitchell, & Patel, 2006; Cochrane, et al., 2001).

There are limited studies which examine the incidence of breast cancer among lesbian
populations, as breast cancer research often does not record sexual orientation. Rates of breast
cancer in lesbian women reflected in the literature ranges from 0.8% to 10%. The significant
variance in the rates is indicative of the age biases in the cohorts of the studies, that is, some
cohorts recruit older populations, whilst others recruit younger ones (Pitts, Smith, Mitchell, &
Patel, 2006; Hyde, Comfort, Brown, McManus, & Howat, 2007).

A study by Pitts et al. found17.2% of lesbians in the target group (over 50s) had never had a
mammogram for cancer of the breast. Whilst this is similar to the unscreened heterosexual
cohort (2006), due to the higher theoretical risks outline above the lesbian population should
be more thoroughly examined for breast cancer incidence in order to more accurately inform
prevalence data (Brown & Tracy, 2008). Additionally, targeted health promotion messages


highlighting these risk factors to lesbians may be beneficial in decreasing the burden of disease
in an already marginalised health care consumer group.

American and British lesbian cohort studies examine rates of health behaviours, including breast
self examination and mammography. However, these studies do not provide useful information
about Australian and Queensland lesbians, particularly in relation to the effectiveness of local
health promotion efforts which aim to encourage these types of behaviours in lesbian women
(Aaron, Mardovic, Danielson, Honnold, Janosky, & Schmidt, 2001; Fish, 2006).

...lesbians do not perceive health promotion
messages for ‘all women’ to include them
regarding sexual health issues.
(McNair et al, 2009)

Cervical Cancer Screening
Cervical cancer is one of the most preventable and curable of all cancers. Over 90% of cervical
cancers result from the human papillioma virus (HPV) (Australian Institute of Health & Welfare,
2009). It is the eighteenth most common cause of cancer mortality in Australian women. It
dropped from eighth place after the introduction of the Cervical Screening Program (CSP). The
CSP uses a Pap smear to detect cervical cellular changes which later lead to cervical cancer
(Australian Institute of Health & Welfare, 2009).

All women who have ever had sex need to have regular Pap smears. This includes women
who no longer have sex (AIHW, 2009). Women should have their first Pap smear around age 18
to 20 or a year or two after first having sex, whichever is the later. They should then continue
to have Pap smears throughout their life until age 70 (AIHW, 2009). ‘Sex’ is not defined in the
above CSP guidelines, though a common and heteronormative interpretation may read ‘sex’ as
intercourse between a man and a woman. The abovementioned guidelines are written for health
care workers, which may influence their advice to lesbian patients. However, it is important to
acknowledge that current social marketing campaigns, such as brochures, from the National
CSP do explicitly mention lesbians (National Cervical Screening Program).

While over 60% of lesbians have had a male sexual partner in their lifetime, many of these
women may exclude themselves from health promotion campaign messages which do not
intentionally include lesbians (McNair, Power, & Carr, 2009). Further, in a study which explored
the knowledge of lesbian and other women who have sex with women about HPV and their
attitudes to the HPV vaccine and cervical screening, it found lesbians do not perceive health
promotion messages for ‘all women’ to include them regarding sexual health issues (McNair et
al, 2009). Due to dominant sexual scripts about what ‘real sex’ is, lesbians often presume that
health messages are not aimed at them because they think that health promoters do not believe
what they do to be ‘real sex’ (Power, McNair, & Carr, 2009).

The Victorian Private Lives Survey reports that 1.5% of the participants had been diagnosed with
cervical cancer (Pitts et al, 2006). In a Western Australian cross-sectional study of lesbian and
bisexual women, 10.6% of the participants had been diagnosed with cancer in their lifetime, 33%
of these women suffered with gynaecological cancer (cervical cancer being one of these) (Hyde et
al, 2007).


Australian comparative studies indicate that about 20% of lesbians report never having had a Pap
smear for cancer of the cervix. About 40-56.8% of the same population reported having a Pap
smear in the last year. This is comparative with heterosexual cohorts (Hyde et al, 2007; Pitts et al,
2006; McNair et al, 2009).

As with breast cancer prevention research, American and British lesbian cohort studies examine
the rates of cervical screening but are unhelpful in providing useful information about Australian
and Queensland lesbians and the effectiveness of local health promotion efforts to encourage
these behaviours in lesbian women (Aaron et al, 2001; Fish, 2006).

Lifestyle factors, poor knowledge of risk factors, a lack of targeted health information for
lesbians and issues of access to appropriate health care, may put lesbians at higher risk than
heterosexual women in developing cancer of the cervix and breast (McNair & Power, 2009). The
QAHC LHAG seeks to raise awareness about cancer prevention among at risk lesbian populations
through persistent, effective health promotion activities. To this end, it endeavours to partnership
with existing health promotion organisations to provide targeted, timely and appropriate health
promotion messages and resources to lesbians and other women who have sex with women.


Stigma and Discrimination

One key factor in women coming out in
any community is the presence of lesbian
role models who are accepted, or at least
tolerated, by the mutual community.

Invisibility
Women who ‘come out’ as lesbians generally suffer some form of psychological distress
during the process. Edwards (2005) in her South Australian study, reports that lesbians in rural
communities are more psychologically affected than their counterparts in metropolitan regions
of Australia. This is due to rural lesbians’ high levels of invisibility. Rural communities, though
generally supportive and close-knit, are difficult places for lesbians due to higher levels of
homophobia (Edwards, 2005). Added to this, living in a rural community places individuals in a
microcosm where anonymity is a fantastical notion. Edwards suggests this leads rural lesbians to
assuming invisibility concerning their sexual orientation and often adopting a public heterosexual
life (2005). Whilst Edward’s study sample was small, her work has been pioneering in uncovering
information about the lives of rural Australian lesbians.

One key factor in women coming out in any community is the presence of lesbian role models
who are accepted, or at least tolerated, by the mutual community. Edwards (2005) identified in
the rural South Australian community, invisibility of role models often meant lesbians remained
closeted even after self-identifying their sexual orientation. One way that women may find role
models in a safe environment is to undertake excursions to larger metropolitan areas where
individuals are more likely to encounter same-sex attracted women (Edwards, 2005). Women
in rural areas who do actualise their same-sex attraction often go to incredible lengths to keep
their relationships secret. One woman in Edward’s study reported hiding on her partner’s car
floor as they drove around their town in order to avoid being spotted by townsfolk (2005). The
psychological stress to concealing so much of one’s personality is considerable and undoubtedly
impacts on a lesbian’s mental health. Further to this, it is likely that ‘the fear of harassment or
ostracism is a prime reason for keeping their same-sex attraction relatively invisible’ (Edwards,
2005). Rural lesbians may benefit from contact with metropolitan lesbians in the form of online
networking sites, wide distribution of gay press and an organised network of lesbian role models
willing to support lesbian and SSAW in rural areas.

Aboriginal, Torres Strait Islanders and Australian South Sea Islander same-sex-attracted
women are benefitting in Queensland from peer support and community connectedness with
the recent development of IndigiLez. The group has identified that Indigenous SSAW experience
health inequities such as discrimination, domestic violence, mental health and wellbeing, lack of
education regarding safe play and safe sex (Jeffreys, 2009). IndigiLez places a focus on developing
leadership skills and empowerment, and addressing issues of racism and discrimination by
offering fortnightly meetings and quarterly ‘Dreaming Retreats’ (Jeffreys, 2009).


Workplace harassment is another reason why lesbians choose to remain invisible or closeted.
Whilst discrimination against a person for their sexual orientation in Australia is illegal, only half
of the LBGTIs surveyed in the Victorian Private Lives Surveyed stated that they were ‘out’ at work
(Pitts et al, 2006). An Atlanta study of lesbian physicians found that the lesbian participants were
four times more likely than their heterosexual counterparts to suffer sexual harassment, in any
setting, but predominantly in their training and medical practice (Brogan, Frank, Sivanesan, &
O’Hanlan, 1999). Any sort of interpersonal stressors in the workplace has a negative impact on
work functioning and satisfaction. The Atlanta study found ‘harassed women physicians are less
satisfied with their careers, feel less in control of their work environments, and are more likely to
have histories of depression and suicide attempts’ (Brogan et al, 1999).

Coming out
Laden with difficulties, the ‘coming out’ process is vital to the self-actualisation of all lesbian, gay
and bisexual (LGB) people. When this process is unsupported and an isolating experience, young
people are more prone to hazardous substance use, suicidal attempts and other risk-taking
behaviour (Floyd & Stein, 2002; Van Wormer & McKinney, 2003). On the other hand, when a LGB
young person is exposed to positive non-heterosexual role models, media and support services
they can emerge from their initial ‘coming out’ experience significantly less scathed (Floyd et al,
2002; van Wormer et al, 2003). The ‘initial’ ‘coming out’ experience is highlighted because for
many LGB people, life can become a constant struggle against heterosexism. A life where one
must correct others’ use of personal pronouns, be relegated to the use of ambiguous terms such
as, ‘my partner’, and assert that ‘sex’ does not always involve ‘just one penis and one vagina’ can
be difficult.

One’s level of acceptance by self and others during adolescence and young adulthood is
predictive in psychological resilience across the lifespan. Health care workers and educators
have a responsibility to provide appropriate role modeling of non-heterosexuality and homophilic
environments where youth can develop self-acceptance as they come out. Fletcher and Russell
provide helpful guidelines for educators to create opportunities to challenge heterosexism
within the classroom context (2001). Though Fletcher and Russell’s article is written for college
teachers, its principles are applicable and perhaps even more appropriate to raise with younger
age groups on the basis of the stage theory for sexual orientation. Fletcher et al suggest using
non-heterosexual examples when illustrating points of discussion in the classroom and creating
a classroom climate where homophobic comments and slurs are as unacceptable as racial and
anti-Semitic remarks (2001).

Women in relationships where each partner
has moderate social involvement with lesbian
affiliated events and social networks reported
the highest level of relationship satisfaction.
(Beals & Peplau, 2001)


Outness
The degree of disclosure about sexual orientation is most often colloquially termed ’outness’ and
it has been long touted that the more ‘out’ one was, they more socially and individually adjusted
they were. ‘Outness’ can become a psychosocial stressor for individuals and couples where
disclosure could be socially detrimental or where the individuals have differing levels of desire
to self-disclose. Women in relationships where each partner has moderate social involvement
with lesbian affiliated events and social networks reported the highest level of relationship
satisfaction (Beals & Peplau, 2001). Beals et al. also found that lesbians who disclosed their
sexual orientation did not report more satisfaction in their relationship than lesbians who did
disclose their sexual orientation (2001). However, couples who disagree about their ‘outness’ to
friends, family and their community are likely to experience conflict due to differing wants and
needs. Couples who have discordant levels of ‘outness’ are more likely to experience conflict
and relationship dissatisfaction than those couples who are out to their friends and family
(Todosijevic, Rothblum, & Solomon, 2005). When considered in the context of the gay liberation
movement which has worked towards increasing lesbian and gay visibility and human rights
touting better lifestyle and health outcomes for being ‘out’, this finding by Beals is surprising
(2005). Beals explains that though self-disclosure can provide benefits, it is burdened with risks,
including:

• social rejection;
• loss of control over personal information;
• betrayal if confidences are broken; and
• the possibility of hurting or embarrassing the listener’ (2005).

Young lesbians whose parents are aware
of their sexual orientation experience less
internalised homophobia and receive more
family support than those youth whose parents
are unaware of their sexual orientation.
(D’Augelli, Grossman, & Starks, 2005).

Acceptance of Loved Ones
The old saying ‘you can chose your friends but you can’t chose your family’ is no more
burdensome than in the lives of lesbians and their families who have to battle the social
conditioning of heterosexism and homophobia to accept their lesbian loved ones and their sexual
orientation. Lesbians have reported more stress related to their family’s acceptance of them
being homosexual than their gay counterparts. Factors included experiencing:

• rejection;
• lack of support; and
• lack of understanding by family (Todosijevic, Rothblum & Solomon,2005).


The Todosijevic et al study concludes it is likely that gay men and lesbians experience equal levels
of rejection by family and that perhaps women perceive family rejection as a more stressful event
(2005). Coming out is most often a traumatic event not only for the individual but also for their
families. The most devastating cases seem to be where a family has failed to pick up on any clues
about homosexuality or where the family is in denial of the cues. Young lesbians whose parents
are aware of their sexual orientation experience less internalised homophobia and receive more
family support than those youth whose parents are unaware of their sexual orientation (D’Augelli,
Grossman, & Starks, 2005).

Lesbians report more stressors than gay men in relation to family acceptance of their chosen
partner (Todosijevic, Rothblum, & Solomon, 2005). The study cited four main stressors for
lesbians, including:

• negative family reaction,
• visibility with family and friends,
• visibility with work and public, and
• sexual orientation conflict (2005).

The study reports that lesbians and gay men reported equal levels of stress related to the
acceptance by loved ones of the individual’s partner choice (Todosijevic et al, 2005).


Mental Health

The trend towards higher
rates of depression and
anxiety among lesbians is
likely to be related to poor
societal acceptance of their
homosexuality and poor
social support, especially
from family.
(Pitts et al., 2006; McNair, Kavanagh, Agius, & Tong, 2005)

Lesbians suffer greater rates of anxiety and depression than heterosexual women. This is due
to a variety of reasons, but mostly because of the stigma and discrimination associated with
homosexuality. Heterosexuals underestimate the impact of living in a heterosexist world for
lesbians where everything is geared to validate heterosexuality. Whether it is the registration
form at the GP’s surgery, the advertising images on the television each night or the questioning
look of your child’s teacher when he states he has two mummies, heterosexism can become
daily drudgery for lesbians. This psychosocial pressure can manifest in anxiety and depression
for lesbians. A Victorian self-completed survey of 178 lesbians revealed that a sense of belonging
to the general community is protective against depression and that a sense of belonging to the
lesbian community supported and facilitated a sense of belonging to the general community
(McLaren, 2009).

Large Australian cohort studies reveal higher rates of anxiety and depression than their
heterosexual counterparts (Hydeet al., 2007; Pitts et al., 2006). One third of Western Australian
lesbian and bisexual women had been diagnosed by a doctor with depression, in comparison with
on 22% of heterosexual women (Hyde, 2007). Forty percent of this same population had been
diagnosed with anxiety by a doctor, nearly 50% of these lesbians had been diagnosed in the last
year (Hyde, 2007).The trend towards higher rates of depression and anxiety among lesbians is
likely to be related to poor societal acceptance of their homosexuality and poor social support,
especially from family (Pitts et al., 2006; McNair, Kavanagh, Agius, & Tong, 2005).

Women who are forced to conceal their same-sex attraction often ‘experienced alienation from
their usual social networks and intensifying psycho-social distress’, according to Edwards (2005)
Edwards suggests that telephone and internet based counseling could provide a means of
support for same-sex attracted women in rural areas (2005).

The Australian Bureau of Statistics (ABS) reports that homosexuals (including lesbians and
bisexual women) have poorer lifetime mental health status, with 30.2% suffering with an affective
disorder (depression) compared with only 8.1% of heterosexuals, and 26% having an anxiety
disorder compared with only 6.6% of heterosexuals (ABS, 2008).


Alcohol, Tobacco and Other Drug Use

This section is provided by the QAHC ATODS Project Officer, Shane Garvey, with permission. The full
ATODS Literature Review can be found on the QAHC website.

Lesbians and bisexual
women are more likely
to smoke and misuse
alcohol, both of which
are linked to major
chronic disease and
risk-taking behaviour in
the case of alcohol use.
(Gruskin, Hart, Gordon, & Ackerson, 2001; King
& Nazareth, 2006)

It may be that lesbians self-medicate to deal with psychosocial stress in ways that could be
potentially harmful to their health. Lesbians and bisexual women are more likely to smoke and
misuse alcohol, both of which are linked to major chronic disease and risk-taking behaviour
in the case of alcohol use (Gruskin, Hart, Gordon, & Ackerson, 2001; King & Nazareth, 2006).
The ABS 2007 Mental Health and Wellbeing Report suggests that 27.5% of homosexual
Queenslanders (including lesbians and bisexual women) suffer with a lifetime substance use
disorder in comparison to only 5.5% of heterosexual Queenslanders (ABS, 2008).

Australian lesbians are more likely than
heterosexual women to smoke.


Tobacco
The literature suggests Australian lesbians are more likely than heterosexual women to smoke.
In Australia, rates of smoking amongst lesbian and bisexual women range from 28% and 45.6%
(Comfort, 2007; Pitts et al., 2006; Hillier, de Visser, Kavanagh, & McNair, 2003). A recent study
reported that one third (34%) of lesbian respondents living in Sydney were current tobacco
smokers (Richters, Song, Prestage, Clayon, & Turner, 2005). In 2007, 28% of lesbian and bisexual
women residing in Western Australia smoked tobacco, twice the general rate for heterosexual
women (Comfort, 2007).

Younger lesbian and bisexual women are more likely to smoke tobacco with 76% of this group
aged between 14-18 having reported smoking, compared to 19% heterosexual females of the
same age (Barbeler, 1992). More recently, in a national longitudinal study of young lesbian
women in Australia aged 22-27 years, just under half (45.6%) were current smokers compared to
25% for heterosexual women within the same age group (Hillier et al. 2005).

Reasons for the elevated use of tobacco by lesbians and bisexual women range from stress and
depression experienced as a result of external and internalised homophobia cultural factors,
including the use of bars as a primary means of socialisation where smoking is prevalent; the
desire to appear more masculine, peer pressure, fitting in, rebelliousness (for youth), exposure
to other LGBT smokers and the perception that LGBT people generally smoke (Heffernan, 1998;
Aaron et al., 2001; Gruskin et al., 2001; Ryan, Wortley, Easton, Pederson, & Greenwood, 2001).

Alcohol
Australian research suggests that patterns of alcohol consumption among lesbians and bisexual
women are not uniform over age, and that younger lesbians are more likely to drink than
heterosexual women and gay men of the same age group (Hyde et al., 2007; Hillier et al., 2005).
In Australia, 38.6% of lesbians have reported low-risk-drinking-with-binging (compared to 27.9%
in heterosexual women) with 7% reporting high risk drinking, compared to 3.9% of heterosexual
women. (Hillier et al., 2003). Research has also indicated that 33% of lesbians in Australia drink
above the recommended safe level of four drinks or less per day (Murnane, Smith, Crompton,
Snow, & Munro, 2000).

In a more recent study 30% of Australian lesbians have reported exceeding the safer drinking
guidelines, whilst only 7% have described themselves as a heavy drinker, suggesting that
“these women (are) unaware that their consumption patterns (are) potentially harmful and that
heavy drinking may be a normalised behaviour amongst lesbian and bisexual women” (Hyde et
al., 2007) .

Some explanations for the differences in lesbian and heterosexual women’s drinking patterns
include the minority stress model, whereby “health disparities are explained by stressors
induced by a homophobic society”, internalised homophobia, and the centrality of the “gay” bar to
socialization and social support- especially during the years of coming out are some explanations
for differences between lesbian and heterosexual women’s drinking patterns (Meyer, 2003;
Williamson, 2000; Eliason & Hughes, 2004).

Parallels have also been drawn between problem drinking and sexual identity development
whereby lesbian women who are younger when they first disclose their sexual orientation, tend
to experience more negative consequences of drinking than women who disclose at a later age,
resulting in a greater number of alcohol dependence symptoms. Therefore, younger lesbians,


most of whom must negotiate an often difficult developmental stage, may be at risk of consuming
alcohol at high levels when dealing with issues related to sexual identity. (D’Augelli et al., 1998 in
Parks & Hughes, 2007). The risks associated with disclosure, or “coming out” can include loss of
family and community support, along with harassment and violence, and this can add additional
stress on the well being of young lesbians (Eliason & Hughes 2004; D’Augelli et al. 1998 in Parks,
2007). Alternatively, “coming out” to family members and social networks, can also increase the
potential for support (Parks, 2007).

Homophobic abuse; testing gender boundaries;
lesbian recreational bar culture; escaping from
isolation and the stress of homophobia are some
of the reasons cited for the elevated use of illicit
drugs by young lesbians.
(Hillier et el, 2003; Hershberger & D?Augelli, 1995; Jordan, 2000)

Illicit Drug Use
In Australia, lesbian and bisexual women are more likely to use and inject illicit drugs than
heterosexual women. In a 2003 study by Hillier et al., 61.2% of lesbians had reported using
illicit drugs in their lifetime (compared to 22.4% of heterosexual women) and 40.7% had used
illicit drugs in the past twelve months (compared to 10.2% of heterosexual women). Over 10%
of lesbians and bisexual women reported injecting illicit drugs compared to only just over 1%
of their heterosexual counterparts. Cannabis was the most commonly used illicit substance,
with 84.6% ever used, and 58.2% used in the past year, far exceeding heterosexual rates of
cannabis use.

Similar rates of illicit drug use can be found in The 2004 Sydney Women and Sexual Health
Survey where cannabis (38.1%), ecstasy (28.3%) and speed (25.3%) had been used by lesbian
and bisexual women aged 16-64 in the past six months. Again, these rates far exceeded illicit
drug use by heterosexual women when compared to the 2004 National Drug Household Survey
(Richters et al., 2005). The most recent research to date into lesbian and bisexual women’s
illicit drug use in Australia confirms these results, with 33.6% of lesbian and bisexual women
having reported using an illicit drug in the past six months, with cannabis (26.4%), ecstasy
(17.9%) and speed (17.3%) being the most commonly used, and10.4% reporting having injected
an illicit substance in the past 6 months (Hyde et al., 2007).

For younger Australian lesbians, cannabis, heroin and injecting drug use exceeds that of
young gay men (Hillier et al., 2005). Homophobic abuse; testing gender boundaries; lesbian
recreational bar culture; escaping from isolation and the stress of homophobia are some of
the reasons cited for the elevated use of illicit drugs by young lesbians. (Hillier et el, 2003;
Hershberger & D’Augelli, 1995; Jordan, 2000). For some, drugs are used as a temporary crutch
to deal with homophobic abuse and the confusion surrounding their sexual orientation. For
many young lesbians, drug use diminished with self acceptance of their sexual orientation.
However, evidence also indicates that for other young Australian lesbians, drug use continued
in to later life, even after self acceptance of sexual orientation had been achieved. (Hillier et al.,
2005).


Relationships

Relationships which are recognised gain the
support and status which validates and normalises
homosexuality, thus improving self-esteem
and mental health and decreasing other health
behaviours which are deleterious and harmful.

Lesbian relationships are intricate and unique. However just like their heterosexual counterparts
lesbian relationships necessitate the same maintenance of a healthy relationship while dealing
with day to day life. Fraught with a lack of acceptance by the mainstream society, lesbian
relationships in Australia remain invalidated in terms of marriage and equal parenting rights.
Additionally, couples may struggle with maintaining a sense of self in emotionally intense unions
which may be known or unknown to friends, family and society.

Civil Unions and Same Sex Marriage
King and Bartlett use the premise that married heterosexual men and women experience greater
health outcomes than their unmarried counterparts to predict that civil unions may yield the
same health benefits for gay men and lesbians (2006). Further to the health benefits of being in
a long-term, committed and supportive relationship, King et al. suggests that legally recognised
relationships may be a step towards reducing the psychological stress and trauma associated
with being homosexual in a heterosexist if not homophobic world (2006).


A recent Australian study investigated the preferences of same-sex attracted Australians
regarding the legal recognition of their relationships following the introduction of de facto
status for same-sex couples at a federal Government level (Dane, Masser, & Duck, 2009). The
study which surveyed 2232 Australians (53% female and 37.9% lesbian) reported that of those
participants who currently had their relationship recognised by a state or municipal registry
(NSW, Victoria, ACT and Tasmania), 78% would prefer to be married to their partner (Dane et al.,
2009). Of those participants who had an overseas marriage, 91% wanted to be legally married
in Australia as well (Dane et al., 2009). The prohibition of same-sex couples to marry is a key
indicator of acceptance of homosexuals in society. Relationships which are recognised gain the
support and status which validates and normalises homosexuality, thus improving self-esteem
and mental health and decreasing other health behaviours which are deleterious and harmful.

Extreme intimacy in relationships
Todosijevic et al. identified that lesbians in civil unions where the couple had a significant age
gap were more likely to have higher relationship satisfaction (2005). The authors purport two
explanations for this phenomenon:

1. that women of all sexual orientations are more likely to express interest in older partners;
which is an acceptable conclusion. More interestingly though;

2. that ‘heterogeneous’ couples are less likely to experience ‘over involvement’ or ‘merging’
than similarly aged couples.

This second hypothesis raises fascinating phenomenological questions about the level of intimacy
which lesbians experience in their relationships. Because of the high level of emotionality
of women, common interests and exemplary communication skills, lesbians in general are
more likely to engage in an extreme emotional connectedness with their partner, than their
heterosexual counterparts. Todosijevic et al. states that this ‘fusion’ can result in ‘near complete
loss of individual identity’ for similarly aged couples (2005). Furthermore, the authors suggest
that an age difference is likely to lead to ‘discordance’ in interests which may assist in fostering a
‘healthy balance between closeness and distance’ (Todosijevic et al., 2005).


Sexual Health

Whilst the literature reflects significant stressors impacting on lesbians, sexual health is
one area lesbians may be ahead of their heterosexual counterparts. Peplau et al. suggests
that lesbian sexuality and relationships are far less about sexual acts than the sexuality and
relationships of their heterosexual female counterparts and all men (2000). The literature cited in
Peplau’s et al. paper suggests that lesbians are:

• less likely than gay men to have sex with a new partner on the first date;
• more likely than gay men to have their first same-sex contact within the context of an
established romantic relationship (70% vs 5%); and
• (along with heterosexual women) are likely to have less sexual partners than all men
are (2000).

Though lesbian sexual behaviours over the lifespan may be protective, rates of STIs (sexually
transmitted infections) among lesbians are surprisingly high based on four premises:

1. most lesbians have had sex with men in their lifetime, and many continue to do so;

2. lesbian sex, particularly orogenital, oroanal and penetrative vaginal sex with body parts and/
or toys, is a viable mode of transmission for STIs;

3. lesbians are more likely than their heterosexual counterparts, to engage in unsafe sex, that
is limited use of barrier methods such as dams for oral sex, condoms/gloves or washing
hands and toys before penetrative vaginal sex; and

4. lesbians are less likely to engage in regular and honest sexual health care with their health
care professionals (Bailey, Farquhar, Owen, & Mangtani, 2006; Marrazzo, 2004).

Higher levels of unsafe sex amongst lesbians are evidenced as in Marrazzo, who reports:

• 19% of lesbians who reported no sex with men were seropositive for HPV,
• 46% of lesbians were seropositive for HSV1 and 8% for HSV2 (Seattle Lesbian
Health Study),
• Between 24% and 51% of lesbians suffered with BV (Bacterial Vaginosis) in comparison
with their heterosexual counterparts who experienced rates of 21% (2005; Bailey et
al., 2006).

Limited safe sex campaigns have been noted in gay press and the issue of lesbian sexual health
remains largely ignored by the general sexual health community. In the lesbian community safe
sex is rarely discussed and certainly not common practice. With the advent of organisations such
as Queensland Association for Healthy Communities, we may hope to expect more attention for
lesbian health in the future, in the form of safer sex awareness raising, affordable supply of dams
and an attitudinal change amongst lesbians.


Pregnancy and Parenting

... children brought up in
lesbian families experience
as much, if not, greater
quality of mother-child
interaction than single-
parent or heterosexual
families, lesbian couples
and families continue to be
subjected to stigmatisation
and discrimination.
(Vanfraussen, Ponjaert-Kristoffersen, & Brewaeys, 2003)

One of the most contentious issues for lesbianism today is the parenting of children within
the lesbian family. Though research proves that children brought up in lesbian families
experience as much, if not, greater quality of mother-child interaction than single-parent or
heterosexual families, lesbian couples and families continue to be subjected to stigmatisation
and discrimination (Vanfraussen, Ponjaert-Kristoffersen, & Brewaeys, 2003). Lesbian invisibility
rears its ugly head in the parenting context for the ‘lesbian social mother’. Though ‘lesbian social
mothers’ (non-birth mothers) are as equally engaged with their children as all of their parenting
counterparts, including the birth mother (Vanfraussen, 2003), they stand in a very precarious
position. With virtually no legal rights regarding decision-making and advocacy for the child, non-
birth mothers are bereft of the capacity to have custody of their child without their relationship
to the birth mother. The psychosocial stress of not being able to consent for her son’s life saving
surgery in the emergency department or having no legal case for joint custody of her daughter if
her relationship ends must be devastating. Vanfraussen states:

‘from a symbolic (linguistically) and legal point of view, the lesbian social mother
remains invisible. Since she has no genetic tie with the children she parents, she cannot
call on biologically based notions of parenthood to define her role as a parent. Instead
she has to construct her role socially as a caregiver’ (2003).

In the Queensland context there are two aspects of the law that are relevant for same-sex
parents; Commonwealth laws and Queensland laws. With the recent amendments to legislation
that came in to effect on July 1, 2009, the state and federal governments have made marginal
progression towards closing the gap in the inequities for same-sex parents.


Domestic Violence

... internalised homophobia was associated with
domestic violence for the 40% of lesbians who had
been physically or sexually violent to a female partner
and 44% who had been victims of domestic violence.
(Balsam et al., 2005)

Minority stress has been described by Balsam and Szymanski as living in an ‘oppressive cultural
context’ where one is ‘stigmatised and marginalised’ (2005). Their small scale study examines
the role of minority stress in relationship quality and domestic violence among lesbians, and
found lesbians with less internalised homophobia had better relationship quality, were more
‘out’ and independent than those with high levels of internalised homophobia (Balsam et al.,
2005). Conversely, internalised homophobia was associated with domestic violence for the 40%
of lesbians who had been physically or sexually violent to a female partner and 44% who had
been victims of domestic violence (Balsam et al., 2005). Most interestingly, Balsam et al. tested
a hypothesis that butch women would be more likely to perpetrate domestic violence and that
femmes would be more likely to be victims (2005). They found that there was no correlation
between stereotyped roles and domestic violence but that femmes may be more vulnerable to
insults regarding their sexual orientation by abusive partners (Balsam et al., 2005).


Obesity and Overweight

Australian Lesbians are more likely than
their heterosexual counterparts to be
overweight (49% vs 38%).
(Pitts et al., 2006)

There has been alarming significant increases in the proportion of overweight or obese
Australians over the last 20 years (Cameron et al., 2003). According to the figures from the AIHW
7.5 million Australians aged 25 years and over (60%) were overweight or obese and of these
2.6 million (21%) were obese (2002). Significantly the proportion of overweight or obese people
increased with age and peaked at 55-74 years for men and 65-74 years for women (Australian
Institute of Health and Welfare, 2002). These local statistics are replicated over the Western world
with the US peaking at 30.9% of their total population as obese (Cameron et al., 2003).

Obesity is measured across the world by Body Mass Index (BMI) which is weight in kilograms
divided by height in metres squared (Caterson, 1999; Crawford, 2002). Individuals with a BMI
greater than 30 are considered obese and are considered morbidly obese with a BMI over 40
(Crawford, 2002).

Australian Lesbians are more likely than their heterosexual counterparts to be overweight
(49% vs 38%) (Pitts et al., 2006). Though, it should be noted that this same population reported
better self-rated and comparable actual health status when compared with the general
Australian population (Pitts et al., 2006). It may be true that as lesbians age, they adjust better
to their sexual orientation and become less susceptible to the societal pressures of being in a
sexual minority.

Furthermore there are many co-morbidities related to being obese which can include arthritis,
sleep apnoea, varicose veins, diabetes, hypertension, ischaemic heart disease, fatty liver,
gallstones, certain cancers and psychosocial difficulties (Caterson, 1999; Hahler, 2002; Martinez-
Owens, 2003) These medical problems often prolong length-of-stay (LOS) within hospitals for
generally routine admissions due to the nature and severity of these problems (Davidson, Kruse,
Cox, & Duncan, 2003;Hahler, 2002). This extended LOS can further exacerbate issues for lesbian
women as they will have had to negotiate their admission and then face further issues relating
to disclosure, recognition of their same sex partner and other issues already discussed in the
Accessing of Health section of this paper.


Health Service Delivery
This section is provided by the National LGBT Health Alliance, with permission.

Sexual orientation should be recognised as a social determinant of health, alongside other
determinants including gender, indigenous, ethnic and socioeconomic status. Research indicates
that stigma, discrimination and other forms of exclusion experienced by lesbians and same sex
attracted women have a detrimental impact on their health behaviours, health outcomes and
access to health services.

Health promotion strategies that combat sources of discrimination and foster resilience, self-
esteem and an attitude of self-care among members of marginalised groups contribute to
positive health outcomes.

Sexual orientation can impact on the health of lesbians in three main ways:

Services need to be
Some health issues Some health issues affect
culturally appropriate to
affect lesbians/wsw more lesbians/wsw differently
lesbians/wsw people to
than other women. than other women.
be effective.

As reported above, there are a range of health behaviours and health outcomes that affect
Lesbians/women who have sex with women more than other women, including mental health,
tobacco & other drugs and sexually transmitted diseases. Health programs and services should
prioritise the needs of gay lesbians/WSW in these areas.

Health issues can also affect lesbians/WSW differently than other women. Sexual health is an
obvious example of where lesbians/WSW are different from heterosexual women. However, as
much health behaviour is socially determined, the social context in which lesbians/WSW live will
influence behaviour in ways different than other women. Health programs and services need to
understand these differences and tailor services appropriately.

Health programs and services need to be delivered in a way that is culturally appropriate to

Lesbians/WSW, including:

• one size fits all
• niche marketing
• custom made
• services specific to lesbians/WSW

One Size Fits All - As most lesbians/WSW access most health services from the mainstream,
these mainstream services have a responsibility to ensure they are knowledgeable and respectful
of issues specific to lesbians/WSW. Services should ensure staff are properly trained, that there
are policies and procedures in place that are inclusive of lesbians/WSW and that they are able to
make referrals to lesbians specific services/resources where appropriate.


Niche Marketing - Mainstream health programs and services should be promoted through
communication channels that target sexuality, sex and gender diverse communities (e.g. press,
websites, groups, venues) as well as in the mainstream, to send a clear message that these
services are inclusive and welcoming of lesbians/WSW. Marketing should explicitly include
images and text that ‘speak’ to lesbians/WSW.

Custom Made – Some mainstream services could be more effective by making adaptations to
make them culturally appropriate to lesbians/WSW. This could include running the service in a
lesbian friendly setting, employing lesbian workers and using language, printed resources and
examples that lesbians/WSW can relate to.

Specific Services – There will also be issues and situations where a lesbian/WSW specific service
is required or preferred. This may be because the issue is more significant or different for
lesbians/WSW. LGBT community based services, known to be run by and for lesbians/WSW are
often most effective as they have fewer barriers to access and an in-depth understanding of the
issues at hand.


Conclusion
Though there are health inequalities for lesbians, as with most other minority groups,
appropriate community support and acceptance would alleviate much of this burden. Individual,
societal and relationship factors all contribute to the health status which an individual enjoys.
Where people can live free from stigma and feel accepted by peers and the community at
large, they flourish as worthwhile contributors to society and are more likely to make healthful
life choices.

The Private Lives survey reports that LGBTI people live ‘happy and fulfilled’ lives, despite their
heterosexist environment, reporting that friends, work/study and relationships were the best
parts of their lives (Pitts et al., 2006). It seems that in gay-friendly communities, lesbians
experience relative freedom and report being well-adjusted. The difficulty remains for young
and closeted lesbians who are enmeshed in homophobic contexts where they are denied,
discriminated against and stigmatised. In these environments, destructive self-soothing
behaviours become a coping strategy for minimising the psychosocial stress of being different
from the majority sexual population. While the militancy of the lesbian feminist appears to be
long gone from mainstream attention, the young, disempowered and isolated remain burdened
with secrets and shame of their love for women. Positive role models from all walks of life are
vital to provide dislocated lesbians with forums to share their experiences and safety to be who
they truly are, women loving women.


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Contact details info@qahc.org.au www.qahc.org.au Statewide Admin: 1800 177 434 Men’s Sexual Health: 1800 155 141

Brisbane & Southern Qld 30 Helen Street, Newstead Qld 4006, PO Box 1372, Eagle Farm BC Qld 4009, P: 07 3017 1777, F: 07 3852 5200,
E: info@qahc.org.au

Sunshine Coast & Central Qld 10 Pikki St, Maroochydore Qld 4558, PO Box 2077, Sunshine Plaza Qld 4558, P: 07 5451 1118, F: 07 5451 1611,
E: ssc@qahc.org.au

Cairns & North Q ld 290 Draper St, Cairns Qld 4870, PO Box 12112, Cairns BC Qld 4870, P: 07 4041 5451, F: 07 4041 6092, E: cns@qahc.org.au

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